Atrial fibrillation (AF) is now said to be at epidemic proportions.1 Although symptoms and heart failure are two of the main reasons that patients with AF suffer from reduced quality of life,
thromboembolic complications, particularly stroke, remain the major determinant of significant morbidity and mortality.2 Importantly, the risk of thromboembolism (TE) is completely irrespective of symptoms, and hence the sad fact that people
continue to present with catastrophic stroke in AF with no prior history of its detection.3 Appropriate anticoagulation is imperative to reduce the TE/stroke risk. Numerous large scale studies have demonstrated the
benefit of appropriate anticoagulation, specifically using coumadin analogues such as warfarin.4 However, despite recognition by all members of the medical community that this risk needs to be addressed, there is still
systematic underuse of anticoagulation5 with the rather depressing statistic that as few as 35% may receive warfarin where it is indicated. In the past this may
have been because there was some uncertainty in physicians’ minds about which patients benefit most, and where the risk of
bleeding complications with warfarin might outweigh the benefits. This risk is usefully assessed using scoring systems such
as the CHA2DS2VASc score6 and HAS BLED score.7 Most of the data available suggest that it is the vast majority of patients with AF who would benefit from formal anticoagulation
with warfarin, and only those at very low risk of TE/stroke do not need warfarin and probably need nothing at all.

But why still the underuse? There are several reasons that are put forward for this. Some patients genuinely are intolerant.
This may be because of side-effects, lifestyle issues, problems with phlebotomy and other factors that preclude the use of
warfarin.8 Fall risk is an issue that predominantly affects the …